AZ Balance of State

Information Needed for Completion of the Continuum of Care and Renewal Application

Current Grantees

Please complete the following information which will be used both in the continuum of care application (formerly exhibit 1) and in your specific project applications. Return both this file and the excel participant file to Candee Stanton by December 14, 2012. Her email address is

If you have any questions, please call her at 602-881-6606.

Legal Name of Organization
Name and title of Authorizing Person for HUD applications
Address of Location if it has changed since last year
Phone and Fax number to use for application if changed from last year / Phone / Fax
Person Completing this Information if different from above
Phone Number
EMAIL
Are there any homeless or formerly homeless persons on your local continuum group?
If there are persons who are formerly homeless—what is their connection to the community?
From your perspective what is the unmet need in your community?—please provide an estimate of the number of beds of each type it would take to address the need for each area / Emergency Services / Transitional Housing / Permanent Supportive Housing
Permanent Supportive Housing for Chronically Homeless
Do you maintain a wait list for housing?
Yes
No
If yes complete information to the right / For Transitional Housing—What was the highest number of persons/families on the wait list? On average how long was the wait until they got into housing?
For Permanent Supportive Housing-- What was the highest number of persons/families on the wait list? On average how long was the wait until they got into housing?
What kinds of activities does the program coordinate or participate in to ensure that 20% or more of participants are employed at exit?
What is happening at the local level to decrease the number of homeless households with children?
If applicable—how many chronically homeless beds did the program have in 2010
If applicable –how many chronically homeless beds did the program have in 2011
If applicable—how many chronically homeless beds did the program have in 2012?
What kinds of program changes, collaborations, or other activities have been developed to improve participant involvement in mainstream resources?
Explain how case managers provide the service of helping participants access mainstream resources? (this could be the agency’s case manager or the agency that you collaborate with to provide case management
Does the program provide transportation assistance to clients to attend mainstream benefit appointment, employment training or a job?
Is there a single form that provides application for four or more mainstream resources? Indicate which mainstream resources are included on the application.
How do staff follow up to ensure benefits are received?

Please record the following information from your latest APR in this table—if you have multiple projects, add the totals from all the APRS together and record the total only.

Item / Value
Total number of persons served
Total number of persons who left
Total number of persons who stayed
Number of persons who were employed at exit regardless of type of program.
Number of participants who received mainstream resources at exit.
Permanent Housing
Number of persons who exited permanent housing projects
Number of persons who did not leave projects
Number of persons who exited after staying six months or longer
Number of persons who did not exit after staying six months or longer
Number of persons who did not exit and were enrolled for less than six months.
Transitional Housing
Number of persons who exited TH projects including unknown destination
Number of SHP TH participants to permanent housing upon exit.
Cash Income Sources at Exit / Number of Exiting Adults
Earned Income
Unemployment Insurance
SSI
SSDI
Veteran’s Disability
Private disability insurance
Worker’s Compensation
TANF or Equivalent
General Assistance
Retirement (Social Security)
Veteran’s Pension
Pension from former job
Child support
Alimony (spousal support)
Other source
No sources
Non Cash Income Sources at Exit / Number of Exiting Adults
Supplemental nutritional assistance program
MEDICAID health insurance
MEDICARE health insurance
State children’s health insurance
WIC
VA medical services
TANF child care services
TANF transportation services
Other TANF funded services
Temporary rental assistance
Section 8 public housing, rental assistance
Other source
No sources

List all the programs that are currently approved Balance of State Continuum of Care projects

Name of Project / Type—i.e. Transitional Housing, Permanent Housing, Permanent Housing for Chronically Homeless / Number of Units Approved in original Technical Submission. / Number of Bedrooms Approved in original Technical Submission. / Number of Beds Approved in Original Technical Submission. / Congressional District(s) that the Project is in / Do you have a contract for this project or is the contract pending?

Provide a description of the project that addresses its entire scope,including the needs of the community/target population, number and type of units and location by city and county (limited to 1500 characters)

Name of Project from Above / Description
Name of Project from Above / Standard Performance Measures / Target # / Universe #
Persons remaining in PH as of the end of the operating year or exiting PH during the operating year.
Persons age 18 and over who maintained or increased their total income as of the end of the operating year or program exit

Other Documents:--All other documents should be emailed to Candee by 12/14/12.

  • Cash Match and Leverage Letters--Please email Candee all of thecash match and leverage letters. As a reminder, cash match is required for everything but leasing. For leverage, the goal is to provide documentation of leverage for at least 100% of the project costs, if you can provide leverage at a rate that is greater than 100%, the COC as a whole will score better. The letters must contain these elements: 1) name of organization providing leverage; 2) the type of contribution—i.e. cash, services, food, volunteer hours; 3) must indicate the specific name of the project it is supporting; 4) provide a value of the contribution, and 5) must include the specific dates (for that specific project) that the contribution is available.
  • 501c3 letter—Please send Candee an updated 501c3 letter for your agency if you have received a new or revised letter since last year’s application.
  • Code of Conduct—if you agency is not listed on the Code of Conduct List which is attached or can be found at

Please send a copy to Candee.

  • For those areas that have a local consolidated plan, we need copies of the signed Consistency with the Consolidated Plan form. This applies to Coconino, Yavapai, and Yuma based projects. The form is attached with this packet.

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